Antibiotic Stewardship Protocol - GrandView Pharmacygrandrx.com/wp-content/uploads/2017/08/GVP_AntimicrobialProtoco… · Antibiotic Stewardship Protocol For Senior Living Communities

Antibiotic Stewardship Protocol

For Senior Living Communities

The Role of Antimicrobial Stewardship Champions

Antimicrobial Stewardship [AS]

Team Development

Antimicrobial Stewardship Education and Training

Antimicrobial Stewardship Communication

Clinical Protocols for Antimicrobial

Stewardship, Infection Management, and Diagnostic Testing

Infection Surveillance

Resident Change Communication

& Documentation

The Role of the Laboratory in Antimicrobial Stewardship

Antimicrobial Use Measurement

Action Steps and Strategies for Implementing Antimicrobial Stewardship

in Long-term Care Facilities

This toolkit is designed to be used by any senior living community; all recommendations can be tailored to accommodate individual community’s needs and resources. There is no “one-size-fits-all” approach for promoting antimicrobial stewardship in post-acute care. Many of the action steps and strategies below may already be in place at the community. Therefore, assessing existing processes for opportunities to incorporate antimicrobial stewardship is recommended.

The term “providers” includes all licensed providers in the senior living community (e.g., MD, DO, NP, PA) regardless of employment status (e.g. full-time, part-time or casual status; on-call; external consultant; etc.).

Identify antimicrobial stewardship champions


•  A physician serves as an antimicrobial stewardship champion to promote adherence to clinical practice guidelines for antimicrobial prescribing


•  Nursing leadership serves as an antimicrobial stewardship champion to promote nursing assessment, documentation, and communication in anti microbial stewardship activities

•  Job Descriptions •  Senior Living Attending Prescriber •  Senior Living Consultant Pharmacist •  Senior Living Medical Director •  Senior Living Nurse Executive


•  A coordinator is assigned to oversee antimicrobial stewardship activities


•  Senior leadership is supportive of antimicrobial stewardship activities

Incorporate antimicrobial stewardship issues into a committee/workgroup

(Antimicrobial Stewardship [AS] Team)



•  Identify a committee/workgroup to incorporate antimicrobial stewardship issues (AS Team). Members may include: antimicrobial stewardship champion(s), nursing leadership, antimicrobial stewardship coordinator, senior leadership, consulting/in-house pharmacist, quality improvement, infection preventionist, information technologist, etc.



•  AS Team develops and communicates roles and responsibilities about antimicrobial stewardship for community stakeholders



•  AS Team members have dedicated time for antimicrobial stewardship activities

•  Explore quality improvement-and resident safety-related grant funding opportunities that could incorporate antimicrobial stewardship activities



•  AS Team regularly reviews antimicrobial use summaries/reports



•  Engage the consulting or in-house pharmacist in antimicrobial stewardship activities, particularly antimicrobial measurement



•  Nursing leadership/nursing champion regularly communicates antimicrobial stewardship progress to nursing assistants and nurses. Progress may include improved shift change hand-offs, compliance with use of Situation – Background – Assessment –Request (SBAR) form, infection rates, communication and documentation of nursing assessments, etc.



•  Medical director/physician champion regularly communicates antimicrobial stewardship progress to licensed providers in the community

•  Consider communicating aggregate and/or individual antimicrobial use results to providers

Published clinical practice guidelines that support antimicrobial stewardship are reviewed by key antimicrobial stewardship stakeholders – at a minimum the medical director/antimicrobial stewardship physician champion, nursing leadership/director of nursing, infection preventionist, consulting/ in-house pharmacist.

Provide regular antimicrobial stewardship education

and training to all healthcare personnel, including providers

Provide regular antimicrobial stewardship education and training to all healthcare

personnel, including providers

•  Provide education and training about antimicrobial stewardship to resident care staff, including providers

Provide education and training to nursing staff at all levels within the community to

promote the timely and accurate recognition, assessment, communication, and documentation of change

in a resident’s condition

Provide education and training to nursing staff at all levels within the community to promote

the timely and accurate recognition, assessment, communication,and documentation of change in a resident’s condition

•  Utilize tools to educate and train nursing staff at all levels within the community to promote the timely and accurate recognition, assessment, communication,and documentation of change in a resident’s condition.

Communicate antimicrobial stewardship messages to healthcare community staff

and resident family and visitors

Develop and communicate policies and protocols based on clinical guidelines for

antimicrobial stewardship, infection management, and diagnostic testing

Communicate antimicrobial stewardship messages to healthcare community staff and resident family and visitors

Develop and communicate policies and protocols based on clinical guidelines for antimicrobial stewardship, infection management, and diagnostic testing

Develop and communicate expectations to all healthcare personnel, including all licensed providers in the community regardless of employment status (e.g. full-time, part-time or casual status; on-call; external consultant; etc.), regarding their roles in antimicrobial stewardship



•  Communicate antimicrobial stewardship messages to all community staff (e.g. via staff meetings, newsletters, etc.)



•  Communicate antimicrobial stewardship messages to family/visitors (e.g. via brochures, newsletters, family council meetings)



•  Develop policies based on clinical practice standards for antimicrobial stewardship (e.g. the 5 Ds: right diagnosis, drug, dose, duration, and de-escalation)



•  Develop policies based on clinical practice guidelines for infection management including prescribing algorithms and clinical pathways(e.g., Loeb et al. (2001), SHEA/IDSA guidelines)



•  Develop standardized policies and protocols for ordering diagnostic tests (e.g., microbiology, imaging) based on clinical guidelines (e.g., High et al., 2008). For example, if UTI is suspected, ensure that clinical criteria (High et al.,2008) are met prior to ordering microbiology tests



•  Communicate policies and protocols for antimicrobial stewardship, infection management, and diagnostic testing to all licensed providers in the LTCF

Evaluate the community’s process to assess,

communicate, and document a resident’s change in condition

Evaluate the community’s process to assess, communicate, and document

a resident’s change in condition •  Perform process mapping to examine key opportunities to

communicate clinical information pertinent to infections and antimicrobial stewardship. This method will demonstrate how antimicrobial stewardship components fit into existing care processes

The community sets the expectation that a change in a resident’s

condition is consistently communicated between nursing assistants and nursing through

the use of a standardized process

The community sets the expectation that a change in a resident’s condition is consistently communicated between nursing assistants and nursing through the use of a standardized process

•  Implement a standardized process to communicate a change in a resident’s condition between nursing assistants and nurses; use findings from process mapping to develop or revise processes

•  Standardized tools provide consistency when communicating a change in a resident’s condition.

•  Provide education and training to staff on the standardized communication process

The community sets the expectation that a change in a resident’s condition is consistently communicated between

nursing and providers through the use of a standardized process

The community sets the expectation that a change in a resident’s condition is consistently communicated between nursing and providers

through the use of a standardized process

•  Implement a standardized process to communicate a change in a resident’s condition in a consistent manner between nursing and providers; use findings from process mapping to develop or revise processes

•  The standardized process should include review of all sources of resident information (e.g.,electronic health record, 24-hour/daily report, shift change report/communication, stand-up meetings, wall boards, etc.)to ensure that clinically-relevant resident information is accessible to the end user (e.g.,nurses, providers, etc.)for clinical decision-making



•  Provide education and training to staff on the standardized communication process



•  Audit the implementation of the standardized communication process (e.g., are nursing staff using standardized communication tools?)

The community sets the expectation that

a change in a resident’s condition

is consistently communicated

between nursing and providers

through the use of a standardized

process



•  Audit the completeness and accuracy of the information included on the standardized communication tool (e.g., SBAR). For example, are nurses thoroughly and appropriately communicating the information required according to the standardized communication tool?

The community sets the expectation that a change in a resident’s condition

is consistently documented



•  Integrate tools for information gathering into the electronic health record when possible to provide consistency, care continuity and centrally documented information (e.g., a UTI monitor)



•  Information Technology support for antimicrobial stewardship activities is available in the community to facilitate accessibility of clinical documentation; activities may include report generation, optimizing electronic health record for clinical documentation, etc.



•  Explore ways your electronic health record vendor can support antimicrobial stewardship activities

Diagnostic testing results, including microbiology, are

accessible in a timely manner for clinical decision-making and infection surveillance

Diagnostic testing results, including microbiology, are accessible in a timely manner for clinical decision-making

and infection surveillance

•  Implement a process to ensure that diagnostic testing, including microbiology results, are accessible in a timely manner for clinical decision-making

Diagnostic testing results, including microbiology, are accessible in a timely manner for clinical decision-making

and infection surveillance

•  Implement a process to ensure that diagnostic testing, including microbiology results, are accessible in a timely manner for infection surveillance

Clinical Protocols for Antimicrobial Stewardship, Infection Management, and

Diagnostic Testing

Clinical Protocols for Antimicrobial Stewardship, Infection Management, and Diagnostic Testing

•  Policies/protocols based on clinical practice guidelines for the initiation of antimicrobials (Loebet al., 2001)are followed by all licensed providers in the community regardless of employment status (e.g. full-time, part-time or casual status; on-call; external consultant; etc.)

•  Consider conducting antibiotic use assessment to monitor guideline adherence


•  All licensed providers follow basic antimicrobial stewardship practices including the 5 Ds: right diagnosis, drug, dose, duration, de-escalation

•  Consider engaging consulting or in-house pharmacist

•  Specifically ensure that all antimicrobial orders have the following elements documented:

•  Diagnosis

•  Treatment indication/ rationale (e.g., specific resident symptoms warranting antibiotics)

•  Treatment site (e.g., urinary tract, lower respiratory tract etc.) DrugDoseDuration

•  Antibiotic start date

•  Antibiotic end dateRoute/ de-escalation



•  Empirically prescribed antibiotics are reviewed by the provider in a timely manner and adjusted or discontinued based on microbiology results


•  All licensed providers in the community follow clinical guidelines/recommendations for asymptomatic bacteriuria management (e.g., Infectious Diseases Society of America (IDSA)Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults 2005.)

•  Consider conducting antibiotic use assessment to monitor

guideline adherence


•  All licensed providers have access to a local antibiogram; consider whether the data are compiled from the community, local hospital, healthcare system, region, etc.; as well as how often the data are updated (e.g.,annually, quarterly, monthly, etc.)


•  Conduct infection surveillance using standardized infection definitions (Stone ND, et al. Surveillance definitions of infections in LTCF: revisiting the McGeer criteria. Infect Control Hosp Epidemiol. 2012;33:965-77.)


•  Infection prevention expertise is available in the community

Measure antimicrobial use


•  Establish an antimicrobial utilization baseline

•  Antimicrobial Use Assessment (Appendix E)


•  Assess antimicrobial use on a regular basis (e.g., monthly, quarterly, etc.)


•  Assess antimicrobial appropriateness on a regular basis (e.g., monthly, quarterly, etc.); this activity is most suitable for the consulting or in-house pharmacist. Assess prescribing trends by provider and community-wide


•  Monitor compliance with prescribing expectations and clinical practice guidelines relevant to antimicrobial stewardship (e.g., monitor compliance with Loebminimum criteria for initiation of antibiotics in LTC residents)

•  Antimicrobial Use Assessment (Appendix E)


•  Develop antimicrobial use summaries/reports on a regular basis

Antibiotc Stewardship Protocol

For Senior Living Communities

Mark Prifogle, HFA, LNHA, CEAL, FACHCA of Indiana

Chief Executive Officer [email protected]

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